Thursday, January 17, 2013

Applauding Baby Steps

Many years ago, I had a patient (let’s call him Tony).

Tony was 48 years old, had a BMI of 43, elevated blood pressure (uncontrolled), reflux disease (Tums PRN), and occasional gout attacks (Tylenol 3s PRN).

Tony fitted every imaginable obesity stereotype – his diet consisted essentially of donuts and pizza (with a few chicken wings and fries thrown in for good measure). He was a self-proclaimed “meat and potato” guy (and proud of it). His daily consumption of beer was essentially unchanged since college.

Tony’s activity levels consisted largely of moving from his bed to his car to his desk to his car to his couch to his bed. HIs idea of exercise was watching Hockey Night in Canada.

When I first saw him, it was immediately apparent that he had no interest in seeing me (or anyone else in the clinic). He was here because his wife threatened divorce unless he lost some weight, his daughter threatened to no longer let him see his grandkids till he changed his attitude and lifestyle, his boss had passed him up for promotion twice because of his size.

Despite this Tony was in complete denial. He was not “obese” (just husky!), hypertension was something invented by the pharmaceutical industry so they can sell drugs, his heartburn was because he had a hernia, his painful toe was because of having stubbed it years ago (the doctors never fixed it!). He felt he was in the best of health for a man in his age and thought this was all a waste of time.

As you may imagine, Tony was not very open to any form of lifestyle counselling. Nevertheless, the rest of the team and I saw him several times over the next six months despite him regularly missing appointments and showing virtually no “progress”.

Finally, after six months of little progress, the team had come to the rather strong opinion that it was time to discharge him from the clinic.

Thus, I was tasked with ‘firing’ him at his next visit.

When Tony came in, he was in a bad mood. His toe had flared up. The pills I had prescribed for his blood pressure were affecting his sexual function. His boss had finally threatened to fire him.

I quietly listened to his complaints and then told him that the team had decided that we felt that we were not helping him and that we saw little point in his coming to see unless he was ready to actually start doing something about his health.

Tony was shocked!

What did I mean by insinuating that he wasn’t doing anything?

He pointed out that he had actually cut down on his drinking (down to four cans from six). He no longer polished off a dozen wings – just half dozens at a time. He had stopped ordering “extra cheese” on his pizza. He had begun wearing a pedometer and some days actually clocked 2000 steps! And, best of all, a week ago he had actually (apparently for the first time in his life), eaten an actual vegetable (a deep fried zucchini), which he had bought for his grand daughter at the rodeo!

And, he pointed out, all of these changes had happened simply because his wife and daughter continued to insist that he come to the clinic.

But, I argued, these may well be changes, but they are simply not enough!

“You are still eating pizza and donuts, you are still drinking, you are still not exercising, you are still not taking your pills, your are still the same weight as before – how can you call this progress? You are just wasting our time. We could be helping other people who really want our help.”

“Please doctor, give me some more time – I am trying – I am trying hard – I just cannot change everything at once. I know I have only made a few ‘baby steps’ but give me time and I promise, things will change for the better. But, if you really think you are wasting your time on me, tell me and I promise you’ll never see me again.”

At that visit, I could have followed the demands of my team – I could have simply discharged Tony for non-compliance.

I chose not to.

Six years later, Tony still occasionally eats pizza, he still drinks a can or two of beer everyday, he still loves donuts and still misses breakfast on most days of the week. The extent of his exercise is essentially taking out the garbage and occasionally mowing the lawn. At least his blood pressure is now controlled and he seems to be in a better mood. Surprisingly, he has managed to lose about 10 lbs.

Has he done enough? Certainly not!

Is there further room for movement? Sure there is!

Would any of these changes have happened, had I simply fired him from the program six years ago? Probably not.

What helped Tony in the end was the fact that we noticed and appreciated his baby steps.

Rather than pointing out all the things that he would still need to do to get healthy, we applauded every little move in the right direction. We cheered him on.

We accepted his reality but kept up our gentle nudging.

But most importantly, we keep the dialogue going.

In the end, what was more important in helping Tony change his lifestyle and improve his health?

The threats from his wife and daughter or the positive encouragement and support from the clinic team?

You decide.

AMS
Mississuaga, ON

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7 Responses to “Applauding Baby Steps”

  1. Paul Boisvert says:

    Most important, he managed to stop gaining weight, and maintain long term a weight that is 10 pounds lighter than before. He also has a better healthy lifestyle and control his blood pressure with less drugs. And even more important, this is what he can afford without too much effort. Congratulations.

  2. Patricia Racine says:

    I am not sure where I would be right now without the help of the wonderful and caring staff at the Bariatric Clinic. I am thinking that I may very well be heavier than I am right now. Nothing seems to have worked for me as far as weight loss, HOWEVER I have maintained my weight for over two years while attending the clinic. Baby steps right?? How true…………making a change in lifestyle is hard, as you get older and health issues and medication make it even harder. So I say, ten pounds down, good for you. I myself have not been able to loose ten pounds, but I still have the support of the team at the clinic after suffering a heart attack one year ago. I am still keeping positive that I WILL see a change once they provide me with one more tool to help with my fight with obesity, you see I am on the list for surgery. I feel blessed to have this clinic in my life that DR. Sharma and his team do not give up on people where others have!!

  3. Catherine Walsh says:

    I always make it a point to list patient accomplishments and have them do the same. Today for one patient, I listed 7 points ( eating breakfast, eating regular meals and snacks, recording her food, being aware of triggers to overeat, not saying “the hell with it” after a bad day, passing on a second cookie, using humor in times of stress) We all need reminding of the positive things that we are doing. It keeps hope alive. What is life without hope?

  4. jodik says:

    I love today’s post Dr. Sharma. Whether you realize this or not, today’s post showed us a side we rarely see; what it takes to be a physician of an obese patient. I am sure not only you, but your entire team, strive to make a positive difference in your patients’ lives. Today you have given us a small glimpse of what mental and emotional exchanges you have with your patients throughout your working day. I can only imagine what conversations you have with yourself to come to a place where “Applauding Baby Steps” is written with such compassion.

  5. MagsCraig says:

    This reminds me of a man I once dealt with who had a BMI of 57, type 2 diabetes, hypertension and atrial fibrillation. he could see no benefit to losing weight, as far as he was concerned he was ‘fine’ and wished people would stop nagging him. By listening and seeing the world from his point of view we discovered that the benefit he would see as being worthwhile would be to be able to ‘climb over the rocks easier’.
    Turns out he enjoyed fishing and it would be easier for him to enjoy his hobby if he could climb over the rocks more easily!
    He did then go on to lose 20kg but unfortunately then failed to attend.

  6. Dagny Kight says:

    As Dr. Brene Brown has illustrated in her ground-breaking research into shame, it is not possible to shame a person into changing their behavior. There may be a brief, temporary response but ultimately, shame is ineffectual.

  7. Peggy Bissell says:

    This post is the answer to the question you asked with your national weight control registry profiles: What is the difference between the people who successfully make lifestyle changes and those who don’t? One very big part of the answer is-constructive relationships. We don’t yet know much about how to create therapeutic relationships that motivate people to make and keep healthy lifestyle changes, but it’s clear that the combination of a relationship with a high quatlity care team and other outside motivators made a big difference for this man.

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In The News

Diabetics in most need of bariatric surgery, university study finds

Oct. 18, 2013 – Ottawa Citizen: "Encouraging more men to consider bariatric surgery is also important, since it's the best treatment and can stop diabetic patients from needing insulin, said Dr. Arya Sharma, chair in obesity research and management at the University of Alberta." Read article

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